Pelvic Fractures

Epidemiology

  • Common in:
    • Young males.
    • Older females (osteoporotic).
  • Causes:
    • Motorcycle accidents > Motor vehicle accidents (MVA) > Falls from height.
  • Risk Factors:
    • Side-on collisions.
    • Size discrepancy between vehicles.

Anatomy

Bony & Ligamentous Anatomy

  • Pelvis components:
    • 2 innominate bones and the sacrum.
  • Innominate bones:
    • Formed by fusion of 3 ossification centers:
      1. Ilium.
      2. Ischium.
      3. Pubis.
  • Anterior connection:
    • Symphysis pubis ligament.
  • Posterior connection:
    • Ligaments:
      1. Anterior & Posterior Sacro-Iliac ligaments.
      2. Sacrotuberous & Sacrospinous ligaments.
      3. Iliolumbar ligament (L5 transverse process to ilium).
    • Note: Posterior ligaments are among the strongest in the body.

Nerve Anatomy

  • Sciatic nerve: Formed by L4-S3 roots (lumbosacral plexus).
  • L5 nerve root: Runs over the sacral ala, 2 cm medial to the SI joint.

Vascular Anatomy

  • Common Iliac Artery:
    • Divides into External and Internal Iliac arteries at the level of the S1 vertebral body.
  • Branches of Internal Iliac Artery:
    • Anterior Branch:
      1. Inferior Gluteal.
      2. Internal Pudendal.
      3. Obturator.
    • Posterior Branch:
      1. Superior Gluteal.
        • Runs along SI joint and exits via the greater sciatic notch.
      2. Iliolumbar.
      3. Lateral Sacral arteries.
  • Posterior Venous Plexus:
    • Drains into the internal iliac veins.
    • Responsible for most bleeding in pelvic fractures.
  • Corona Mortis:
    • Connection between Obturator and External Iliac arteries.
    • Location: Superior pubic ramus, 6 cm lateral to symphysis pubis.
    • Can be arterial or venous.

Surgical Approaches and Risks

  1. Kocher-Langenbeck Approach:
    • Risk: Sciatic nerve, Superior Gluteal Artery (may require retraction).
  2. Ilioinguinal Approach:
    • Risks: Obturator nerve, Corona Mortis, Lateral Femoral Cutaneous nerve.
  3. Stoppa Approach:
    • Risk: Corona Mortis.
  4. Anterior or Percutaneous SI Joint Approach:
    • Risk: L5 nerve root.

Pelvic Stability

  • Stability is determined by:
    • Degree of injury to the posterior pelvis.
  • Key Points:
    • Posterior sacroiliac ligaments: Last structure to be disrupted, leading to vertical, lateral, and rotational instability.
    • Rotational instability:
      • Can occur with disruption of anterior ligaments alone (e.g., sacrotuberous, sacrospinous, anterior sacroiliac).
    • Iliolumbar ligament disruption:
      • Indicated by L5 avulsion fractures.
      • Equivalent to posterior iliac and sacral fractures.

Clinical Evaluation

Haemodynamics

  • Predictors of major haemorrhage:
    1. Haematocrit <30%.
    2. Heart Rate >130 bpm.
    3. Wide displacement of fractures.
    4. Obturator ring fractures.
    5. Large symphysis diastasis.
  • Sources of haemorrhage:
    • Bony, venous (most common), or arterial.
    • Disruption of the pelvic floor (ligaments and muscles) can lead to massive haemorrhage.
  • Initial Resuscitation:
    • 2L isotonic fluid bolus.
    • If unstable, commence blood products:
      • Packed Red Cells (PRC).
      • Fresh Frozen Plasma (FFP).
      • Platelets (1 unit for every 4 units of PRC and FFP).

Neurological Status

  • Commonly injured nerves:
    • Lumbosacral plexus, L5, and S1 nerve roots.
    • Femoral and Pudendal nerves.

Gastrointestinal Injury

  • Signs:
    • Abdominal pain (visceral injuries).
    • Rectal examination for tears (constitutes an open fracture).

Genitourinary Injury

  • Signs:
    • Blood at meatus.
    • High-riding prostate.
    • Perineal bruising.
  • Workup:
    • Retrograde urethrogram before catheterisation.
    • Use suprapubic catheter for bladder injury.
  • Notes:
    • Male urethra is more mobile and commonly injured (bulbous urethra most affected).
    • Injury Correlation:
      • APC injury → Predictive of bladder injury.
      • LC injury with ramus fracture → Predictive of urethral injury.

Radiologic Examination

  • X-rays: AP, Inlet, and Outlet views.
  • CT scan: If stable.

Inlet View

  • Assesses anterior-posterior displacement.

Outlet View

  • Assesses vertical displacement.

Classification

Tile Classification

Grade Features
A Stable in all planes
B Rotationally unstable
C Rotationally and vertically unstable

Young & Burgess Classification

  • Mechanistic classification.
  • Categories:
    • APC (Anterior Posterior Compression): Grades 1-3.
    • LC (Lateral Compression): Grades 1-3.
    • VS (Vertical Shear).
    • Combined injuries.
  • Key Notes:
    • Higher grades = greater energy and instability.
    • LC fractures: Transverse ramus fractures.
    • APC fractures: Vertical ramus fractures (may occur instead of symphysis diastasis).

Management

Acute Management Algorithm

  1. Follow ATLS Protocol and screen for life-threatening injuries.
  2. Assess pelvic injuries for:
    • Open fractures.
    • Perineal injuries.
    • Morel-Lavallée lesion.
    • Neurological injury.
    • Haemodynamic instability.
    • Fracture pattern on X-rays.
  3. Resuscitation:
    • Goal-directed resuscitation (normalize lactate, coagulopathy, HR, BP).
    • Early transfusion (PRC, FFP, platelets).
    • Consider cryoprecipitate and tranexamic acid.

Haemorrhage Control Methods

  1. Binder or External Fixator:
    • Stabilizes fractures, provides tamponade.
    • Shown not to significantly reduce pelvic volume.
  2. Angiography & Embolisation:
    • 20% of pelvic fractures involve arterial haemorrhage.
    • Predictors: Pelvic AIS >3 and transfusion >0.5 units/hour.
  3. Pelvic Packing:
    • Place large swabs around the bladder, SIJ, and retropubic space.
  4. Acute Internal Fixation:
    • Plate symphysis pubis or place iliosacral screws.
  5. Clamp Aorta or Iliac Vessels:
    • For severe haemorrhage.

Definitive Management

Indications for Surgery

  • Unstable fractures.
  • Wide symphysis diastasis (>2.5 cm).

Techniques

  • Anterior Ring:
    • ORIF (plating for symphysis or ramus fractures).
    • External fixation for contaminated wounds or poor soft tissue.
  • Posterior Ring:
    • Percutaneous screws for SIJ disruptions.
    • ORIF with tension band plates for sacral fractures.
    • Iliolumbar triangular fixation for maximum stability.

Complications and Outcomes

Mortality

  • Early mortality:
    • Massive haemorrhage.
    • Concurrent injuries (better predictor of mortality).
  • Late mortality:
    • Sepsis.
    • Predictors: Open fractures, severe soft tissue injury (Morel-Lavallée).

Functional Outcomes

  • Neurological injury is the main predictor of poor outcomes.
  • Specific Outcome Measure: Majeed score.

Other Complications

  • Sexual Dysfunction:
    • Occurs in 61% of males (19% with persistent erectile dysfunction).
    • Associated with APC injuries.
  • Urologic Problems:
    • Bladder dysfunction, urethral stricture, incontinence, impotence.
  • Thromboembolism:
    • High risk for DVT and PE.
    • Fatal PE occurs in 2%; DVT in 20-50%.
Back to top